Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Tuesday, September 27, 2005

Anybody who isn't paranoid these days is nuts

As we have just seen to our horror, it is important to have it all figured out ahead of time who is going to be in charge in an emergency. The World Health Organization, as those of you know who have surfed on over to Effect Measure, is considerably worried about the prospect of a worldwide pandemic of a particularly virulent strain of influenza, which is currently percolating away among birds, including domesticated fowl in Asia and migratory birds which have now made it to Eastern Europe. Many readers here are familiar with the basics, but it won't hurt to do a brief review.

As a reminder of the technical background, the problem is that this strain of influenza virus has a form of the protein hemmaglutinin on its outer coat that humans have not previously been exposed to. (That's what the "H5" means in the name of this strain, H5N1, with N1 being the form of another protein called Neuraminidase.) That means we have no immunity to this particular strain. So far we know of a few dozen people who have become infected, about half of whom have died, but it appears they either became infected directly from birds, or from very close contact with severely ill people. Unfortunately for people and birds, influenza virus evolves rapidly, both by mutation and by genetic reassortment, including swapping genes with other strains.

Once a variant of H5N1 influenza acquires the means to be transmitted efficiently from human to human, the pandemic will begin. That may be happening right now in Indonesia. In any event, WHO and most experts believe it is only a matter of time. A strain that easily spreads among people will likely be less lethal, but it will be lethal enough. Ordinary seasonal influenza kills people, but mostly people who are already debilitated or immunocompromised. Frail elderly people are particularly at risk. Like the 1918 strain of flu, however, an H5N1 pandemic is expected to be potentially lethal to young, healthy people. And it will make a lot of people very sick.

Far beyond the direct effects of the virus, a pandemic will create enormous social disruption. Undoubtedly countries will try to protect themselves by restricting travelers from abroad, even suspending all air traffic. If many people in essential occupations such as police, firefighters, physicians and nurses, even trash collectors are sick at the same time, public services will be disrupted including health care, just when we need it most. Internal commerce may also be disrupted, shortages of food and other goods could appear in particular cities, and so on. Undoubtedly many people with the means to do so will flee affected cities for what they consider to be safer retreats in the countryside, leaving yet more jobs unfilled. All of this will pass -- the pandemic will sweep through a region and move on in a few weeks -- but it won't be pleasant.

Naturally, the WHO is calling upon all nations to prepare. They've even given us a handy checklist. Here's one item:

1.2 Command and control

In order to be able to make clear and timely decisions and to have a uniform policy that is endorsed by all officials, it is essential to know who is in charge of different activities within communicable disease control, and how that might change if a limited outbreak becomes a major emergency. In addition, it is essential to know who is in charge of key elements in the response (e.g. travel or trade bans, enforcement of quarantine).

As we saw in the recent unpleasantness in New Orleans and points south and east, the federal gummint hadn't figured that out when it comes to natural disasters. Is it CDC, DHS, local officials? Fearless Leader has the answer! It's the army.

Now, you'd think that people at the Centers for Disease Control and Prevention would have the appropriate expertise here; and that FEMA ought to know something about disaster response. What the army is extremely good at is blowing stuff up and killing people. Hey, that's their job. They have also shown themselves to be highly capable at rounding up large numbers of people and imprisoning them. (Not that there's anything wrong with that.) I don't think that's exactly what's needed, although, as WHO also tells us:

1.5.1 Legal issuesRationaleDuring a pandemic, it may be necessary to overrule existing legislation or (individual) human rights. Examples are the enforcement of quarantine (overruling individual freedom of movement), use of privately owned buildings for hospitals, off-license use of drugs, compulsory vaccination or implementation of emergency shifts in essential services. These decisions need a legal framework to ensure transparent assessment and justification of the measures that are being considered, and to ensure coherence with international legislation (International Health Regulations).

Well, one possible legal framework would be the declaration of martial law and the assertion of presidential emergency powers. Of course, we can count on that being reversed once the emergency is over, right?